State PPE & COVID Supplies Request Form

State-sourced COVID-19 Safety Supplies Request Form

Use this form to request PPE and COVID-19 safety supplies listed below when items are not available through traditional procurement methods. Cloth face coverings will be purchased and distributed centrally (2 per person) for all employees. This form may also be used to request additional cloth face coverings for visitors, students, contractors, etc.

Name*

First Name

Last Name

Email*

Phone*

Area*

Physical Address*

Address Line 1

Address Line 2

City

State

ZIP Code

Index Code*

Cloth Face Coverings

5 per bag

$ 35.00

Quantity:

Gloves (Small)

100 pair per box

$ 7.25

Quantity:

Gloves (Medium)

100 pair per box

$ 7.25

Quantity:

Gloves (Large)

100 pair per box

$ 7.25

Quantity:

Gloves (Extra Large)

100 pair per box

$ 7.25

Quantity:

Sanitizer

1 Gallon

$ 25.00

Quantity: